CONTINENTAL AMERICAN INSURANCE COMPANY PO Box 427 Columbia, South Carolina

Transcription

1 CONTINENTAL AMERICAN INSURANCE COMPANY PO Box 427 Columbia, South Carolina Group Short Term Disability Income Insurance Certificate of Coverage Short Term Disability insurance provides financial protection by paying a benefit in the event of a disability. POLICYHOLDER: LEGENDS GAMING, LLC. DBA DIAMOND JACKS CASINO POLICY NUMBER: 22405S POLICY EFFECTIVE DATE: 01/01/2019 GOVERNING JURISDICTION: LOUISIANA Continental American Insurance Company (referred to as Continental American) welcomes You as a Certificateholder. This is Your Certificate of Coverage as long as You are eligible for coverage and You become insured. Your benefits and rights under the policy will not be less than those stated in this Certificate of Coverage. We certify that You are insured for the benefits described in this Certificate of Coverage, subject to the provisions of this Certificate of Coverage. READ YOUR CERTIFICATE CAREFULLY AND KEEP IT IN A SAFE PLACE. INSURANCE BENEFITS MAY BE SUBJECT TO CERTAIN REQUIREMENTS, REDUCTIONS, LIMITATIONS AND EXCLUSIONS. Your coverage may be canceled or changed under the terms and provisions of the policy. Contact the Policyholder if You wish to inspect a copy of the policy. We will only make changes that are consistent with Interstate Insurance Product Regulation Commission ( the Commission ) standards and any endorsements or amendments used to effect such changes are subject to prior approval by the Commission and shall not affect the insurance provided until the effective date of the change, unless retroactivity is required by the Interstate Insurance Product Regulation Commission. If the terms and provisions of the Certificate of Coverage (issued to You) are different from the policy (issued to the Policyholder), the policy will govern. Your coverage may be canceled or changed under the terms and provisions of the policy. The policy is delivered in and is governed by the laws of the Governing Jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. For purposes of effective dates under the policy, all days begin at 12:01a.m. Standard Time at the Policyholder s address. For purposes of ending dates under the policy, all days end at 12:00 midnight Standard Time at the Policyholder s address. CONFORMITY WITH INTERSTATE INSURANCE PRODUCT REGULATION COMMISSION STANDARDS The policy and this certificate have been approved under the authority of the Interstate Insurance Product Regulation Commission and issued under the Commission standards. Any provision of the policy and this certificate that on the provision s effective date is in conflict with Interstate Insurance Product Regulation Commission standards for group disability income insurance is hereby amended to conform to the Interstate Insurance Product Regulation Commission standards for group disability income insurance as of the provision s effective date. ICC17 C

2 The insurance department name and phone number of the Governing Jurisdiction appear on the listing following the Table of Contents. This policy does not cover disabilities due to an Occupational Sickness or Injury. The policy does not replace or affect the requirements for coverage by any Workers Compensation or state disability insurance. ICC17 C

3 CERTIFICATE OF COVERAGE TABLE OF CONTENTS PAGE NUMBER COVER PAGE... 1 TABLE OF CONTENTS... 3 STATE INSURANCE DEPARTMENT CONTACT INFORMATION... 4 BENEFITS AT A GLANCE... 6 DEFINITIONS... 9 GENERAL PROVISIONS BENEFIT INFORMATION OTHER BENEFITS CLAIM INFORMATION ICC17 C

4 STATE INSURANCE DEPARTMENT CONTACT INFORMATION State Insurance Department Main Phone Alabama Alabama Department of Insurance (334) Alaska Alaska Division of Insurance (907) Arizona Arizona Department of Insurance (602) Arkansas Arkansas Insurance Department (501) Colorado Colorado Division of Insurance (303) Georgia Georgia Department of Insurance (404) Hawaii Hawaii Insurance Division (808) Idaho Idaho Department of Insurance (208) Illinois Illinois Department of Insurance (217) Indiana Indiana Department of Insurance (317) Iowa Division of Insurance (515) Kansas Kansas Department of Insurance (785) Kentucky Kentucky Office of Insurance (502) Louisiana Department of Insurance (800) Maine Maine Bureau of Insurance (207) Maryland Maryland Insurance Administration (410) Massachusetts Division of Insurance (617) Michigan Michigan Department of Insurance and (877) Financial Services Minnesota Minnesota Department of Commerce (651) Mississippi Mississippi Insurance Department (800) Missouri Missouri Department of Insurance, Financial Institutions and Professional Registration (573) ICC17 C

5 STATE INSURANCE DEPARTMENT CONTACT INFORMATION State Insurance Department Main Phone Nebraska Nebraska Department of Insurance (402) Nevada Nevada Division of Insurance (775) New Hampshire New Hampshire Department of Insurance (603) New Jersey New Jersey Department of Banking and (609) Insurance New Mexico Office of Superintendent of Insurance (505) North Carolina North Carolina Department of Insurance (855) Ohio Ohio Department of Insurance (614) Oklahoma Oklahoma Department of Insurance (405) Oregon Oregon Insurance Division Consumer (503) Advocacy Unit Pennsylvania Pennsylvania Department of Insurance (717) Puerto Rico Puerto Rico Department of Insurance (787) Rhode Island Rhode Island Insurance Division (401) South Carolina South Carolina Department of Insurance (803) Tennessee Tennessee Department of Commerce & (615) Insurance Texas Texas Department of Insurance (800) Utah Utah Department of Insurance (801) Vermont Vermont Division of Insurance (802) Virginia Virginia Bureau of Insurance (804) Washington Washington State Office of Insurance (360) West Virginia Offices of the Insurance Commission (304) Wisconsin Office of the Commissioner of Insurance (608) ICC17 C

6 BENEFITS AT A GLANCE - SHORT TERM DISABILITY The Short Term Disability policy provides financial protection for You by paying a portion of Your income while You are disabled. The amount You receive is based on the amount You earned before Your disability began, subject to all policy provisions. This is a Non-Contributory Insurance plan. NAME OF EMPLOYER: LEGENDS GAMING, LLC. DBA DIAMOND JACKS CASINO POLICY NUMBER: 22405S Eligible Class(es): You must be an Employee of the Employer and in an Eligible Class. Temporary workers are excluded from coverage. Seasonal workers are excluded from coverage. Persons who are not legal residents or citizens of the United States are not eligible for coverage. ALL ACTIVE FULL-TIME DIRECTORS Eligibility Date: If You are working for Your Employer in an Eligible Class, the date You are eligible for coverage is the later of: The policy effective date; or The day after You complete Your Waiting Period. When Coverage Begins: When Your Employer pays 100% of the cost of Your coverage under the policy (Non-Contributory Insurance), You will be covered at 12:01 a.m. Standard Time at the Policyholder s address on the date You are eligible for coverage. When You and Your Employer share the cost of Your coverage under the policy (Contributory Insurance) or when You pay 100% of the cost yourself (Contributory Insurance), You will be covered at 12:01 a.m. Standard Time at the Policyholder s address on the latest of: The date You are eligible for coverage, if You Enroll for coverage on or before that date; The first day of the month following the date You Enroll for coverage, if You Enroll within 31 days after the date You become eligible for coverage; or The first day of the month following the date We approve Your Enrollment Form, if Evidence of Insurability is required. In order for Your coverage to begin, You must be in Active Employment. Your coverage is subject to payment of full Premium when due. Minimum Hours Requirement: 30 hours per week Waiting Period: For persons in an Eligible Class on or before the policy effective date: End of the month in which You complete a continuous period of 60 Day(s) of Active Employment. ICC17 C

7 For persons entering an Eligible Class after the policy effective date: End of the month in which You complete a continuous period of 60 Day(s) of Active Employment. Rehire: If Your employment ends and You are rehired within 12 month(s), Your previous work while in an Eligible Class, will apply toward the Waiting Period. All other policy provisions apply. Who Pays for the Coverage: Your Employer pays the cost of Your coverage. Waiver of Premium: Premium payments are not required for Your coverage beginning the first of the month following 30 consecutive days of disability, and thereafter while You are receiving Short Term Disability payments. Elimination Period: The latest of: 14 consecutive days for Injury due to Injury. 14 consecutive days for Injury due to Sickness. The elimination period begins on the first day of Your disability. Benefits for a Payable Claim begin the day after the elimination period is completed. Weekly benefit: 60% of Weekly Earnings to a Maximum Benefit of $2, per week. Your benefit may be reduced by any Deductible Sources of Income and adjusted by any Disability Earnings. Some disabilities may not be covered or may have limited coverage under the policy. Maximum Benefit Amount without Evidence of Insurability: $2,500 per week Weekly Earnings: Weekly Earnings" means Your average weekly income as figured: From the income box on Your W-2 form which reflects wages, tips and other compensation received from Your Employer for the tax year just prior to Your date of disability; or For the period of Your employment with Your Employer if You did not receive a W-2 form prior to Your date of disability. Average weekly income is Your total income before taxes. It does not include deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It does not include income received from bonuses, car, housing or moving allowance, Employer contributions to a qualified deferred compensation plan, or income received from sources other than Your Employer. ICC17 C

8 Earnings, whether for a full year or partial year, will be converted to a weekly amount for the purpose of calculating the Weekly Payment. Maximum Period of Payment: 24 weeks Support Services: The policy may include enrollment, risk management and other support services related to the Policyholder s benefit program. The above items are only highlights of the policy. For a full description of Your coverage, including any additional benefits, exclusions or limitations that may apply, continue reading Your Certificate of Coverage. ICC17 C

9 DEFINITIONS Accident means a sudden, unexpected event that was not reasonably foreseeable. Active Employment means You are working for Your Employer for earnings that are paid regularly and that You are performing the Material and Substantial Duties of Your Regular Occupation. You must be working at least the minimum number of hours as described under the Minimum Hours Requirement in the BENEFITS AT A GLANCE. To be in active employment, Your work site must be: Your Employer s usual place of business; or An alternative work site at the direction of Your Employer, including Your home; or A location to which Your job requires You to travel. We will consider You to be in active employment on weekends, holidays, and planned vacations that Your Employer has approved in advance and during a temporary business closure not to exceed 15 day(s) if You were in active employment on the last scheduled work day immediately prior to such time off. A temporary business closure includes a closure due to inclement weather, power outage or public health agency orders. Temporary workers are excluded from coverage. Seasonal workers are excluded from coverage. Appropriate Care means that You: Visit a Doctor as frequently as medically required according to standard medical practice to effectively treat and manage Your disabling condition(s); and Receive care or treatment appropriate for the disabling condition(s), conforming with standard medical practice, by a Doctor whose specialty or experience is appropriate for the disabling condition(s) according to standard medical practice; and Have the obligation to minimize Your disabling condition including having corrective treatment or minor surgery. Certificateholder means the person who is eligible for benefits provided by the Policyholder s policy and who has received a Certificate of Coverage. Contribution means the amount the Policyholder may require an Insured Person to pay towards the total Premium that We charge for the insurance provided under the policy. Contributory Insurance means insurance for which the Policyholder requires the Insured Person to pay all or a portion of the Premium. The Certificate of Coverage specifies who pays the cost of the coverage. Deductible Sources of Income means income from other sources as listed in the certificate which You receive or are eligible to receive while You are disabled. This income will be subtracted from Your Gross Weekly Payment. Disability Earnings means the income which You receive from working while You are disabled, plus the earnings You could receive if You were working to Your Maximum Capacity. Disability earnings do not include earnings from secondary employment if such employment began prior to Your date of disability; however, it does include any increase in earnings from the secondary employment occurring after Your date of disability. Doctor means: A person performing tasks that are within the limits of his or her medical license; and A person who is licensed to practice medicine and prescribe and administer drugs or to perform surgery; or ICC17 C

10 A person with a doctoral degree in Psychology (Ph. D. or Psy. D.) whose primary practice is treating patients; or A person who is a legally qualified medical practitioner according to the laws and regulations of the Governing Jurisdiction. We will not recognize You or Your family members including, but not limited to, Spouse, domestic partner, child(ren), parents, including in-laws, or siblings, including in-laws, a business or professional partner, or any person who has a financial affiliation or business interest with You as a doctor for a claim that You send to Us. Eligible Survivor means Your Spouse, if living; otherwise, Your child(ren). Employee means a person who is in Active Employment with the Employer in the United States. Employer means the Policyholder and includes any division, subsidiary, or affiliated company named in the policy. For Contributory Insurance: Enroll means You have completed the process of applying for coverage under the policy. Enrollment Form means the application, approved by Us, You complete and submit to Us to apply for coverage under the policy. Evidence of Insurability means a statement of Your medical history that We will use to determine if You are approved for coverage. Evidence of insurability will be provided at Our expense. Evidence of insurability is not required for Non-Contributory Insurance. Evidence of Insurability Form means the portion of the Enrollment Form that You complete and submit to Us that contains a statement of Your medical history. Grace Period means the 31 day period following the premium due date during which premium payment for the policy may be made by the Policyholder. Gross Weekly Payment means Your benefit before any reduction for Deductible Sources of Income any adjustment for Disability Earnings. Hospital, Health Facility or Institution means an accredited facility licensed according to state and local laws to provide care and treatment for the condition causing Your disability. The facility must be supervised by one or more Doctors with 24 hour registered graduate nursing staff. The facility may specialize in treating alcoholism, drug addiction, chemical dependency or Mental Illness. A facility specializing in treating alcoholism, drug addiction, chemical dependency or Mental Illness does not include a rest home, convalescent home, and home for the aged or a facility primarily for custodial or educational care. Insured Person means a person who is eligible for the coverage under this policy, becomes covered according to the terms of the policy, and whose coverage remains in effect according to the terms of the policy. Law, Policy, or Act means the original enactments of the law, policy, or act and all amendments. Leave of Absence means You are absent from Active Employment for a period of time that has been agreed to in advance in Writing by Your Employer. Your normal vacation time or any period of disability is not considered a leave of absence. Material and Substantial Duties means the important duties, tasks, functions and operations that: Are normally required for the performance of Your Regular Occupation; and ICC17 C

11 Cannot be reasonably omitted or modified, except that if You are required to work on average in excess of 40 hours per week, We will consider You able to perform that requirement if You have the capacity to work 40 hours per week. Maximum Benefit means the total Weekly Benefit amount for which You are insured under the policy subject to all policy provisions. Maximum Capacity means, based on Your restrictions and limitations, the greatest extent of work You are able to do in Your Regular Occupation. Maximum Period of Payment means the longest period of time We will make payments to You for any one period of disability. Mental Illness means a psychiatric or psychological condition classified in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), published by the American Psychiatric Association, most current as of the start of a disability. Such disorders include, but are not limited to, psychotic, emotional or behavioral disorders, or disorders related to stress or to substance abuse or dependency. If the DSM is discontinued or replaced, these disorders will be those classified in the diagnostic manual then used by the American Psychiatric Association as of the start of a disability. If the APA no longer publishes a DSM or the APA ceases to exist, We may substitute a comparable DSM subject to the approval by the Commission. Non-Contributory Insurance means insurance for which the Policyholder does not require the Insured Person to pay any part of the Premium. The Certificate of Coverage specifies who pays the cost of the coverage. Occupational Sickness or Injury means a Sickness or Injury that was caused by or aggravated by any employment for pay or profit. Part-time Basis means the ability to work and earn from 20% through 80% of Your Weekly Earnings. Ability is based on capacity and not market availability. Payable Claim means a claim for which We are liable under the terms of the policy. Policyholder means the Employer to whom the policy is issued and who sponsored the coverage for its Employees. Policy Month means the month that begins on the effective date of the policy. Subsequent policy months will begin on the same day of each subsequent calendar month. Premium means the amount the Policyholder will pay to Us for the insurance provided under the policy. Pre-existing Condition means any condition for which You have done, or for which an ordinarily prudent person would ordinarily have done, any of the following at any time during the 3 months just prior to Your effective date of coverage, whether or not that condition is diagnosed at all or is misdiagnosed: Received medical treatment, advice, consultation, or diagnostic testing; or Taken or were prescribed drugs or medicine. Prior Policy means the Policyholder s group short term disability income insurance plan for which You were insured on the day prior to the effective date of Our policy. Recurrent Disability means a disability which is: Caused by a worsening in Your condition; and Due to the same cause(s) as Your prior disability for which We made a Weekly Payment. ICC17 C

12 Regular Occupation means the occupation You are routinely performing when Your disability begins. We will look at Your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location. Retirement Plan means a defined contributions plan or defined benefit plan. These are plans which provide retirement benefits to Employees and are not funded entirely by Employee contributions. Retirement plan includes but is not limited to any plan which is part of any federal, state, county, municipal or association retirement system. Sickness means illness, disease or disability resulting from complications due to pregnancy. Disability resulting from the sickness must begin while You are covered under the policy. Signed means any method executed or adopted by a person with the present intention to authenticate a record, and which is on or transmitted by paper, electronic or telephonic media, and which is consistent with applicable law. Spouse means Your lawful spouse or any other person required to be covered as Your spouse under the civil union, domestic partnership, marriage or other family or domestic relations law of the Governing Jurisdiction. If You reside in a state different from the Governing Jurisdiction of the policy, the Certificate of Coverage shall, if required, comply with the applicable civil union, domestic partnership, marriage or other family or domestic relations law of the state in which You reside. Third Party means any person or entity whose act or omission, in full or in part, caused You to suffer a disability for which benefits are paid or payable under this policy. Third party also includes Your homeowner s, automobile or other insurance company if they make payments to You because of the acts or omissions of another person or entity. Vocational Rehabilitation Plan means a Written plan that a vocational rehabilitation professional, designated by Us, prepares in accordance with the VOCATIONAL REHABILITATION SERVICES provision of the policy. Waiting Period means the continuous period of time (shown in the BENEFITS AT A GLANCE) that You must be in Active Employment in an Eligible Class before You are eligible for coverage under the policy. Weekly Earnings means Your gross weekly income from Your Employer as stated in the BENEFITS AT A GLANCE. Weekly Payment means Your benefit after any Deductible Sources of Income and any Disability Earnings have been subtracted from Your Gross Weekly Payment. We, Us, and Our means Continental American Insurance Company. Written or Writing means a record which is on or transmitted by paper, electronic or telephonic media, and which is consistent with applicable law. You and Your means an Employee who is eligible for coverage under the policy. ICC17 C

13 GENERAL PROVISIONS Entire Contract The insurance for Insured Persons is provided under a contract of group disability income insurance with the Policyholder, and the entire contract with the Policyholder consists of: All policy provisions and any amendments and endorsements to the policy; The Certificate of Coverage and any amendments and endorsements to the Certificate of Coverage; The Policyholder s Signed application; and For Contributory Insurance, the Insured Persons Signed Enrollment Forms. Certificate of Coverage This Certificate of Coverage is a Written statement prepared by Us and may include attachments. It tells You: The coverage to which You may be entitled; To whom We will make a payment; and The limitations, exclusions and requirements that apply within the policy. Changes to Your Coverage Once Your coverage begins, any increased or additional coverage will take effect immediately if You are in Active Employment or if You are on a covered Leave of Absence. If You are not in Active Employment due to Injury or Sickness, any increased or additional coverage will begin on the date You return to Active Employment. Any decrease in coverage will take effect immediately but will not affect a Payable Claim that occurs prior to the decrease. If You are not in Active Employment when Your Employer Replaces Insurance Coverage with Our Policy (Continuity of Coverage) If You are not in Active Employment due to Injury or Sickness on the date Your Employer changes insurance carriers to Our policy, and You were covered under the Prior Policy at the time Your Employer s coverage under Our policy became effective, We will provide continuity of coverage under Our policy. In order for this provision to apply, the Prior Policy's coverage must be similar to Our policy. If You are not in Active Employment due to Injury or Sickness on the effective date of Our policy, and You would otherwise be eligible to become insured under Our policy, We will provide Limited Coverage under Our policy. Coverage under this provision will begin on Our policy effective date and will continue until the earliest of: The date You return to Active Employment; or The end of any period of continuance or extension provided under the Prior Policy. If You are not in Active Employment due to Leave of Absence on the date Your Employer changes insurance carriers to Our policy, and You were covered under the Prior Policy at the time Your Employer s coverage under Our policy became effective, We will provide continuity of coverage under Our policy. In order for this provision to apply, the Prior Policy's coverage must be similar to Our policy. If You are not in Active Employment due to Leave of Absence on the effective date of Our policy, and You would otherwise be eligible to become insured under Our policy, We will provide Limited Coverage under Our policy. Coverage under this provision will begin on Our policy effective date and will continue until the earliest of: The date You return to Active Employment; or ICC17 C

14 The end of any period of continuance or extension provided under the Prior Policy; or The date coverage would otherwise end, according to the provisions of Our policy. Your coverage under this provision is subject to payment of Premium. For the purposes of this provision the following definition applies: Limited Coverage means benefits payable will be paid as if the Prior Policy had remained in effect and You continued to be insured under that policy. We will reduce Your payment by an amount for which the prior carrier is liable. If coverage ends under this provision, or if You were not covered under Your Employer's Prior Policy on the date that policy terminated, the WHEN COVERAGE BEGINS provision under Our policy will apply. If You Have a Disability Due to a Pre-existing Condition After Your Employer Replaces Insurance Coverage With Our Policy (Continuity of Coverage) In order for this provision to apply, the Prior Policy s coverage must be similar to Our policy. We may send a payment if Your disability is caused by, contributed to by or results from a Pre-existing Condition if: You were covered under the Prior Policy at the time Your Employer changed insurance carriers to Our policy; and You have been continuously covered under Our policy from the effective date of Our policy through the date Your disability began. In order to receive a payment, You must satisfy the PRE-EXISTING CONDITION LIMITATION provision under: Our policy; or The Prior Policy, if benefits would have been paid had that policy remained in force. If You satisfy the PRE-EXISTING CONDITION LIMITATION provision of Our policy, We will determine Your payments according to Our policy s provisions. If You do not satisfy the PRE-EXISTING CONDITION LIMITATION provision of this policy, but You do satisfy the Prior Policy s Pre-existing Condition provision: Your Weekly Payment will be the lesser of: a. The Weekly Payment that would have been payable under the terms of the Prior Policy if it had remained in force; or b. The Weekly Payment under Our policy; and Benefits will end on the earlier of: a. The date benefits end under Our Policy, as described under the DURATION OF PAYMENTS provision; or b. The date benefits would have ended under the Prior Policy if it had remained in force. If You do not satisfy either Our policy s or the Prior Policy s Pre-existing Condition provision, We will not make any payments. We will require proof that You were insured under the Prior Policy. All other provisions of Our policy will apply. If You Have a Disability Due to a Prior Disability After Your Employer Replaces Insurance Coverage With Our Policy (Credit for a Prior Disability) You do not have to complete the ELIMINATION PERIOD under this policy if, after Your disability ended under the Prior Policy for which You received a disability benefit, You: ICC17 C

15 Returned to work for Your Employer for 14 consecutive days or less; and Become disabled under the terms of this policy due to the same cause(s) as Your prior disability. We will require proof that You received disability benefits for the prior disability under the Prior Policy. All other provisions of Our policy will apply. If You Are on a Leave of Absence After Your Coverage Begins If You are on a Leave of Absence, and if all Premium is paid when due, Your coverage may be continued beyond the date You are no longer in Active Employment, limited to the time periods described below. If You are on a Leave of Absence as described under the Family and Medical Leave Act of 1993 ( FMLA ) or applicable state family and medical leave law ( State FML ), and Your Employer s human resource policy provides for continuation of disability coverage during an FMLA or State FML Leave of Absence, Your coverage will be continued until the end of the later of: The leave period permitted by the federal Family and Medical Leave Act of 1993 and any amendments; or The leave period permitted by applicable state law. If You are on a Leave of Absence other than an FMLA or State FML Leave of Absence, and if all Premium is paid when due, You may be covered through the end of the month that immediately follows 1 month(s) after the date You stopped Active Employment. If You are on a Leave of Absence for active military service as described under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), Your coverage may be continued until the end of the later of: The length of time the coverage may be continued under the Certificate of Coverage for an FMLA or State FML Leave of Absence; or The length of time the coverage may be continued under the Certificate of Coverage for a Leave of Absence other than an FMLA or State FML Leave of Absence. If Your Employer has approved more than one type of Leave of Absence for You during any one period that You are not in Active Employment, We will consider such leaves to be concurrent for the purpose of determining how long Your coverage may continue under the policy. If Your coverage is not continued during an FMLA or State FML Leave of Absence, and You return to Active Employment immediately following the end of Your FMLA or State FML Leave of Absence, Your coverage will be reinstated. We will not apply a new Waiting Period or require Evidence of Insurability. If Your coverage is not continued during a Leave of Absence for active military service, and You return to Active Employment, Your coverage shall be reinstated in accordance with USERRA. In no event will Your coverage under the policy be continued beyond the date Your coverage would otherwise end according to the terms of the WHEN YOUR COVERAGE ENDS provision. Waiver of Premium Your disability insurance Premium will be waived if You qualify as described below. You must be disabled through Your elimination period. Your elimination period is as stated in the BENEFITS AT A GLANCE and is the period of continuous disability You must satisfy. ICC17 C

16 The Policyholder may continue premium payments until We notify the Policyholder of the date Your disability insurance Premium waiver begins. For insurance to continue under the group policy, full Premium when due is required. Your Waiver of Premium will begin the first of the month following 30 consecutive days of disability, provided You meet the following conditions: You remain Disabled during the elimination period; You meet the notice and proof of claim requirements for disability, as described in the CLAIM INFORMATION section of the certificate, while Your disability insurance is in effect; Your claim is approved by Us; and All required Premiums have been paid until We have approved the Waiver of Premium. We will send You Written notice advising whether You are approved for the Waiver of Premium and, if approved, the amount of Premium being waived. If We approve Your claim, We will not require further premium payments for You while You remain Disabled according to the terms and provisions of the policy. Your disability insurance amount will not increase while Your disability insurance Premiums are being waived. Your disability insurance amount will reduce or cease at any time it would reduce or cease if You had not been Disabled. Premiums waived under this provision will not be deducted from any benefits paid under the policy. If You die and You are entitled to any refund of Premiums that You have paid, when We receive proof that You have died, We will refund any Premiums as follows: If You are insured for Group Term Life Insurance with Us, We will pay the beneficiary You designated. If You are not insured for Group Term Life Insurance with Us, We will pay Your Eligible Survivors. If You have no Eligible Survivors, payment will be made to Your estate. When Your Waiver of Premium Ends Your Waiver of Premium will automatically end on the earliest of the following: The date You are no longer Disabled; The date You fail to submit proof of continuing disability; The end of the Maximum Period of Payment shown in the BENEFITS AT A GLANCE; The date Premium has been waived for 52 weeks and You are considered to reside outside the United States or Canada. You will be considered to reside outside these countries when You have been outside the United States or Canada for a total period of 6 months or more during any 52 consecutive weeks for which Premium has been waived; or The date You die. There is no limit to the number of times You are eligible for the Waiver of Premium. When Your Coverage Ends Your coverage under the policy ends on the earliest of: The date the policy is canceled; The date You are no longer in an Eligible Class; The date Your Eligible Class is no longer covered; The end of the period for which You paid Premiums, if You stop making a required Premium Contribution; The end of the Policyholder s Grace Period if the Policyholder does not remit Premium to Us by the end of such period; or The last day You are in Active Employment, except as provided under a covered Leave of Absence. ICC17 C

17 Legal Action You can start legal action regarding Your claim 60 days after proof of claim has been given to Us, and before the applicable statute of limitations has expired but not after 3 years from the date of proof of claim is required unless otherwise provided under federal law. Incontestability We consider any statements made by You a representation and not a warranty. No statement made by You will be used to reduce or deny any claim or to cancel Your coverage unless: The statement is in Writing on an Enrollment Form or Evidence of Insurability Form that is Signed by You; and A copy of that statement is given to You, Your Eligible Survivor or legally authorized representative. No statement made by You relating to Your insurability will be used to contest the insurance for which the statement was made after the coverage has been in force for two years. For any applied for increases in coverage or reinstatement of coverage, a new two year contestability period is applicable to the amount of the applied for increase or reinstated coverage. Fraudulent statements will be used to contest the insurance for which the fraudulent statement was made when permitted by applicable law in the state where the Certificate is delivered or issued for delivery. No statement made by You will be used to contest the insurance under the policy unless the statement is material to the risk accepted by Us. Clerical Error Clerical error or omission by Us or the Policyholder will not: Prevent You from receiving coverage, if You are entitled to coverage under the terms of the policy; or Cause coverage to begin or continue for You when the coverage would not otherwise be effective. If We or the Policyholder make a clerical error in keeping data that is required to compute Premiums and administer the terms of the policy, We will: Use the facts to decide whether You have coverage under the policy and in what amounts; and Make a fair adjustment of the Premium. Misstatement of Age If Premiums applicable to You are based on age and You have misstated Your age, there will be a fair adjustment of Premiums based on Your true age. If the benefits applicable to You are based on age and You have misstated Your age, there will be an adjustment of said benefits based on Your true age. We may require satisfactory proof of Your age before paying any claim. Workers Compensation or State Disability Insurance The policy does not replace or affect the requirements for coverage by any workers compensation or state disability insurance. Agency For purposes of the policy, the Policyholder acts on its own behalf or as Your agent. Under no circumstances will the Policyholder be deemed Our agent. ICC17 C

18 Extension of Benefits If a disability for which Weekly Benefits are payable begins while Your coverage under the policy is in force, benefits will be payable after termination of Your coverage to the same extent as if the coverage had not terminated. ICC17 C

19 SHORT TERM DISABILITY BENEFIT INFORMATION Definition of Disability You are considered disabled when We review Your claim and determine that, due to Your Sickness or Injury: You are unable to perform all the Material and Substantial Duties of Your Regular Occupation; and You have a 20% or more loss in Your Weekly Earnings. The loss of a professional or an occupational license or certification does not, in itself, constitute disability. Elimination Period You must be continuously disabled through Your elimination period. Your elimination period is as stated in the BENEFITS AT A GLANCE and is the period of continuous disability You must satisfy before You are eligible to receive benefits under the policy. The elimination period begins on the first day of Your disability. Benefits for a Payable Claim begin the day after the elimination period is completed. When You Receive Payments You will begin to receive payments when We approve Your claim, providing the elimination period has been met, You are under the Appropriate Care of a Doctor, and You are disabled. We will send You a Weekly Payment at the end of each Week for any period for which We are liable. After the elimination period, if You are disabled for less than 1 week, We will send You 1/7 th of Your Weekly Payment for each day of Your disability. To Whom Payments Are Made We will pay Your benefits to You unless this certificate specifies otherwise. If any amount for which We are liable remains unpaid when You die, We will pay that amount according to the TIME PAYMENT OF CLAIMS provision in this certificate. If, however, it is necessary for the establishment of a guardianship or conservatorship, or appointment of a trustee, executor or administrator, We may withhold further benefits until sufficient evidence is provided to Us that any such establishment or appointment has been finalized. We will pay benefits within 30 days of receiving sufficient evidence of the establishment or appointment. If We pay benefits on or after the 31 st day of receiving sufficient evidence, the delayed payment will be subject to a simple 10% interest rate per year, beginning with the 31 st day and ending on the day benefits are paid. Amount of Payment A. If You are Disabled and Not Working, or Disabled and Working and Your Disability Earnings are Less Than 20% of Your Weekly Earnings We will follow this process to figure Your payment: Multiply Your Weekly Earnings by 60%. The Maximum Benefit is $2,500 per week. Compare the answer from Item 1 with the Maximum Benefit. The lesser of these two amounts is Your Gross Weekly Payment. Subtract from Your Gross Weekly Payment any Deductible Sources of Income. ICC17 C

20 The amount figured in Item 4 is Your Weekly Payment. B. If You are Disabled and Working, and Your Disability Earnings are at Least 20% But Less Than or Equal To 80% of Your Weekly Earnings You will receive payments based on the percentage of income You are losing due to Your disability. We will follow this process to determine Your Weekly Payment: Subtract Your Disability Earnings from Your Weekly Earnings. Divide the answer in Item 1 by Your Weekly Earnings. T he result is Your percentage of lost earnings. From Your Gross Weekly Payment, subtract any Deductible Sources of Income. Multiply the answer in Item 2 by the answer in Item 3. The answer in Item 4 is Your Weekly Payment. C. If You are Disabled and Working, and Your Disability Earnings are More Than 80% of Your Weekly Earnings If You are working and Your Disability Earnings are more than 80% of Your Weekly Earnings, no benefit will be payable. If You are able to perform all the Material and Substantial Duties of Your Regular Occupation and Your Disability Earnings are more than 80% of Your Weekly Earnings, no benefit will be payable. We may require You to send proof of Your Disability Earnings each week. We will adjust Your payment based on Your Weekly Disability Earnings. As part of Your proof of Disability Earnings, We can require that You send Us appropriate financial records that We believe are necessary to substantiate Your income. After the elimination period, if You are disabled for less than 1 week, We will send You 1/7 th of Your Weekly Payment for each day of disability. If Your Disability Earnings Fluctuate If Your Disability Earnings routinely fluctuate widely from week to week, We may average Your Disability Earnings over the most recent three weeks to determine if Your claim should continue. If We average Your Disability Earnings, We will not terminate Your claim unless the average of Your Disability Earnings from the last three Weeks exceeds 80% of Your Weekly Earnings. We will not pay You for any Week during which Your Disability Earnings exceed the amount allowable under the policy. In no event will benefits be paid beyond the Maximum Period of Payment. We Will Never Pay More Than 100% of Weekly Earnings If You are eligible to receive benefits under the policy in addition to the Weekly Payment and You are participating in a Vocational Rehabilitation Plan, the total benefit payable to You on a weekly basis (including all benefits provided under this policy) will not exceed 100% of Your Weekly Earnings. Deductible Sources of Income ICC17 C

21 With the exception of retirement payments, amounts earned or received from any form of employment and amounts received from any unemployment compensation law, We will only subtract Deductible Sources of Income which are payable as a result of the same disability. The following are Deductible Sources of Income: The amount that You receive, or are eligible to receive, as disability income payments under any: a. State compulsory benefit act or law; b. Individual disability income Plans which are paid for by the Policyholder and purchased on or after the effective date of this policy to the extent that cumulative benefits payable would exceed Your Weekly Earnings; c. Military disability benefit plan; d. Governmental retirement system as a result of Your job with Your Employer; or e. Other group insurance policy with the Employer. The amount You receive as disability income payments under any "no fault" motor vehicle plan. The amount You receive as a result of any action brought under Title 46, United States Code Section 688 (The Jones Act, the Maritime Doctrine of Maintenance and Cure, or the Doctrine of Unseaworthiness) The amount You receive from a Third Party (after subtracting attorney s fees) by judgment, settlement or otherwise. The amount You receive under any Salary Continuation or Accumulated Sick Leave plan. The amount that You: a. Receive as disability payments under Your Employer s Retirement Plan; or b. Voluntarily elect to receive as retirement payments under Your Employer s Retirement Plan. c. Receive as retirement payments when You reach the later of age 62 or normal retirement age, as defined in Your Employer's Retirement Plan. Disability payments under a Retirement Plan will be those benefits which are paid due to disability and do not reduce the retirement benefit which would have been paid if the disability had not occurred. Retirement payments will be those benefits which are paid based on Your Employer s contribution to the Retirement Plan. Disability benefits which reduce the retirement benefit under the plan will also be considered as a retirement benefit. Regardless of how the retirement funds from the Retirement Plan are distributed, We will consider the Employer and Employee contributions to be distributed simultaneously throughout Your lifetime. Amounts received do not include amounts rolled over or transferred to any eligible Retirement Plan. We will use the definition of eligible Retirement Plan as defined in Section 402 of the Internal Revenue Code including any future amendments which affect the definition. The amount that You, Your Spouse, or Your child(ren) receive, or are eligible to receive, as disability payments because of Your disability under: a. The United States Social Security Act; b. The Canada Pension Plan; c. The Quebec Pension Plan; or d. any similar plan or act. ICC17 C

22 The amount that You receive as retirement payments or the amount Your Spouse or Your child(ren) receive as retirement payments because You are receiving retirement payments under: a. The United States Social Security Act; b. The Canada Pension Plan; c. The Quebec Pension Plan; or d. any similar plan or act. We will not reduce Your payment by Your Social Security retirement income if Your disability begins after age 65 and You were already receiving Social Security retirement payments. The amount You earn or receive from any form of employment. If You have income from secondary employment, and such employment began prior to Your date of disability, the amount of income You were receiving from that secondary employment before Your disability began is not a Deductible Source of Income. Any increase in income from that secondary employment occurring after Your date of disability is a Deductible Source of Income. The amount You receive from any unemployment compensation law. If You Qualify for Deductible Sources of Income When We determine that You may qualify for benefits for which You are eligible in the Deductible Sources of Income section, We will estimate Your entitlement to these benefits. We can reduce Your benefit under the policy by the estimated amounts if such benefits: Have not been awarded or denied; or Have been denied and the denial is being appealed. Your Gross Weekly Payment will NOT be reduced by the estimated amount if You: Apply for the disability payments for which You are eligible in the Deductible Sources of Income section and appeal Your denial to all administrative levels We determine are necessary; and Sign Our form. This form states that You promise to pay Us any overpayment caused by an award and We shall be entitled to impose a constructive trust on any such award. If Your Gross Weekly Payment has been reduced by an estimated amount, Your Gross Weekly Payment will be adjusted when We receive proof: Of the amount awarded; or That benefits have been denied and all appeals We determine are necessary have been completed. In this case, a lump sum refund of the estimated amount will be made to You. If You receive a lump sum payment from any Deductible Source of Income, the lump sum will be pro-rated on a Weekly basis over the time period for which the sum was given. If no time period is stated, the sum will be pro-rated on a Weekly basis from the date of the award over Your expected lifetime as determined by Us. We will not estimate Your entitlement to the following: Payments You receive as disability payments under Your Employer s Retirement Plan; Payments You voluntarily elect to receive as retirement payments under Your Employer s Retirement Plan; ICC17 C

23 Payments You are eligible to receive as retirement payments when You reach the later of age 62 or normal retirement age, as defined in Your Employer s Retirement Plan; The amount You receive as disability income payments under any automobile liability insurance policy or "no fault" motor vehicle plan, whichever is applicable; or The amount You receive from a Third Party (after subtracting attorney s fees) by judgment, settlement or otherwise as disability income payments. Non-Deductible Sources of Income We will not subtract from Your gross weekly payment income You receive from the following: 401(k) plans; Profit sharing plans; Thrift plans; Tax-sheltered annuities; Stock ownership plans; Credit disability insurance; Non-qualified plans of deferred compensation; Pension plans for partners; Military pension plans; Franchise disability income plans; Individual disability plans paid for by the Insured Person; A Retirement Plan from another employer; Individual retirement accounts (IRA). Minimum Payment The Minimum Payment each week for a Payable Claim is: 10% of Your Gross Weekly Payment. We may apply this amount to recover an outstanding overpayment. Duration of Payments We will send You a payment each Week up to the Maximum Period of Payment. Your Maximum Period of Payment is stated in the BENEFITS AT A GLANCE and will be paid during a continuous period of disability. When Payments End We will stop sending You payments and Your claim will end on the earliest of the following: The end of the Maximum Period of Payment; The date You are no longer disabled under the terms of the policy; The date You fail to submit proof of continuing disability; The date You die; When You are able to return to work in Your Regular Occupation on a Part-time Basis but You do not; The date Your Disability Earnings exceed 80% of Your Weekly Earnings. EXCLUSIONS AND LIMITATIONS Disabilities Not Covered Under the Policy ICC17 C